The use of noninvasive ventilation (NIV) has increased considerably over the last two decades and is now widespread in the acute-care setting for management of acute respiratory failure (ARF). A guideline committee selected 11 questions relating to the clinical application of NIV for various etiologies of ARF based on their perceived clinical importance, and assessed the evidence currently available to develop corresponding recommendations [1].

Oxygenation and ventilation impairment after planned extubation is frequent. Post-extubation respiratory management aims to decrease the risk of early acute respiratory failure and reintubation, which is associated with a poor prognosis (1).

Acute respiratory distress syndrome (ARDS) is characterized by an inflammatory pulmonary edema resulting in severe hypoxemia. The recent LUNG SAFE study showed that ARDS is common in the ICU, occurring in 10% of all patients admitted (1).

Hyperoxemia can be defined as an increase in arterial oxygen partial pressure (PaO2) to a level greater than 120 mmHg (16 kPa) (1, 2). It is considered to be moderate for levels ranging between 120 and 200 mmHg, and severe if PaO2 exceeds 200 mmHg (27 kPa) (3). Hyperoxemia is caused by hyperoxia (an increase in oxygen) and occurs in 22% to 50% of mechanically ventilated patients in the ICU (1, 3-6).

The Lung Safe study Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries (1) evaluated the recognition, incidence, mortality and management of ARDS in 450 ICU’s in 50 countries. The results of the study may be somewhat surprising in comparison to common perceptions.

Due to the complications associated with mechanical ventilation, clinicians should implement strategies to liberate patients from mechanical ventilation as soon as the underlying cause for mechanical ventilation has sufficiently improved, and the patient is able to maintain spontaneous breathing unassisted.

Optimal patient-ventilator synchrony is of prime importance, as asynchronies lead to increased work of breathing and patient discomfort, and are also associated with higher mortality and prolonged mechanical ventilation (1, 2, 3).

High flow oxygen therapy combines several physiological effects: Oxygenation, PEEP, an increase in the end-expiratory lung volume (EELV), a lower respiratory rate (RR), a decrease in intrinsic PEEP and work of breathing, lower PaCO2, and improved humidification and comfort (1, 2). The optimal flow setting depends on the indications and the desired physiological effect.

Airway driving pressure is associated with clinical outcomes in ARDS, post-surgical, and normal-lung patients, and is a measure of the strain applied to the respiratory system and the risk of ventilator-induced lung injuries. Evidence suggests we should keep driving pressure below 14 cmH2O. But how can we measure it?

The American Thoracic Society and the American College of Chest Physicians recently provided recommendations to help optimize liberation from mechanical ventilation in adult ICU patients (1). They suggest using a ventilator liberation protocol and performing spontaneous breathing trials (SBTs) with modest inspiratory pressure support (5-8 cmH2O). So how do we implement these recommendations using the Adaptive Support Ventilation (ASV) mode?